Provider Demographics
NPI:1508567942
Name:BRADDOX, MALLISSYA
Entity Type:Individual
Prefix:
First Name:MALLISSYA
Middle Name:
Last Name:BRADDOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 N GERMANTOWN PKWY
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-3327
Mailing Address - Country:US
Mailing Address - Phone:901-509-8347
Mailing Address - Fax:
Practice Address - Street 1:1727 N GERMANTOWN PKWY
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-3327
Practice Address - Country:US
Practice Address - Phone:901-509-8347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician